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Chapter 9

Recording and Reporting

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Medical RecordsRecording referred to (process of writing information)

Other words (Reporting, Documenting, Charting, and Recording) .

Medical (health) records are written collections of information about a person’s health, the care provided by health practitioners, and the client’s progress

Also known as health records or client records (files)

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Uses of Medical Records1. Permanent account

The record is filled and maintained for future references.2. Sharing information

Continuing of care. Prevent duplication or omission

3. Quality assurance Continues quality improvement. To improve the quality of care.

4. Accreditation (Official Approval)5. Reimbursement (To pay the coasts of documented care).

6. Education and research7. Legal evidence

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Components of Medical Records

1. Person’s health information

2. Care provided by health practitioners

3. The client’s progress

4. The plan for care

5. Medication cycle

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Types of patient's records

1. Source-Oriented Records Organized according to source of documented

information Contain separate forms for physicians, nurses,

dietitians, physical therapists to make written entries about their specific activities in relation to client’s care

This record provides fragmented documentation Consider of traditional type of record

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2. Problem-Oriented Records

Organized according to client’s health problems

Four major components: data base, problem list, plan of care, progress notes

Information arranged to emphasize goal-directed care; promote recording of pertinent information; facilitate communication among health care professionals

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Components of Problem-Oriented Records

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Methods of Charting1. Narrative charting

Style of documentation generally used in Source-Oriented Records. Involve writing information about the patient and patient's care in a

chronologic order.

2. SOAP charting Style of documentation more likely to be used in a Problem-

Oriented Record. S = Subjective Data. O = Objective Data.. A = Analysis of the Data.. P = Plan for care.

Some agencies have expanded the SOAP format to SOAPIE or SOAPIER I = Interventions E = Evaluation R = Revision to the plan of care

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Methods of Charting (cont’d)

3. Focus charting (DAR model is used )

D = Data A = Action R = Response

4. PIE charting P=Problem I=Intervention

E=Evaluation

5. Charting by exception Method in which only abnormal assessment finding are written.

6. Computerized method Documenting patient information electronically

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DOCUMENTING INFORMATION

Abbreviations

Abbreviations shorten length of documentation and documentation time

Agencies provide list of approved abbreviations and their meanings

Use only abbreviations on agency’s approved list

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DOCUMENTING INFORMATION (cont’d)Documentation Time

1. Traditional time

– Two 12-hour revolutions; identified with hour and minute, followed by a.m. or p.m.

2. Military time

– Based on 24-hour clock; uses different four-digit number for each hour and minute of the day

o First two digits indicate hour within 24-hour period

o Last two digits indicate minutes

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Documentation Time (cont’d)

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Charting Guidelines

Should not be time-consuming to write and readEveryone involved in the care of a client should make

entries in the same location in the chartThe nurse should address specific content in charted

progress notesAssessments should be documented on a separate form Information should always be clear

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Charting Guidelines (cont’d)

Abnormal assessment findings, or care that deviates from the standard, should also be documented separately

Client information should be documented electronically

Abbreviations and terms should be consistent with agency-approved lists

The date of the documentation should be recorded

The time of the documentation should be recorded

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Written Forms of Communication1) Nursing care plan: list of client’s problems, goals,

and nursing orders for client care

2) Nursing Kardex: quick reference for current information about client and client care

3) Checklists: documentation with check mark or initials

4) Flow sheets: documentation with sections for recording frequently repeated assessment data

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Other Forms of Communication1. Change of shift reports: Discussion between a nursing

spokes person from the shift that is ending and personnel coming duty.

2. Client assignments: Are made at the beginning of each shift.

3. Team conferences : Are commonly used for exchanging information

4. Rounds : Visit to patients on an individual basis or as group

5. Telephone calls

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Nursing Documentation